Failure to Document and Label Respiratory Tubing Changes for Resident with Tracheostomy
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident receiving respiratory care, specifically by not documenting the change of oxygen tubing as ordered by the physician. The resident, a female recently admitted with diagnoses including cerebral infarction and tracheostomy status, had physician orders requiring all disposable respiratory tubing and equipment to be changed weekly on Sundays. However, review of the medication administration record revealed no documentation indicating when the tubing was last changed. Observations showed the resident was receiving continuous oxygen therapy, but the tubing was not labeled with the date of last change. Interviews with the respiratory therapist, nursing staff, and administration confirmed that the tubing should have been labeled and changed according to the physician's order, but this was not done. Staff admitted to forgetting to label the tubing and not checking for labeling during their shifts, despite having received training on tracheostomy care. Further review indicated that the facility's policy on tracheostomy care did not address procedures for disposable respiratory tubing. Multiple staff members, including the ADON and interim DON, acknowledged the expectation to follow physician orders and label tubing, but there was a lack of documentation and oversight to ensure compliance. Training records were either not provided or outdated, and the failure to document and label the tubing was recognized by staff as a lapse in care.